Sexual changes

Families and partners can have trouble understanding how impulsivity, disinhibition and lack of awareness can lead to sexual changes and can react negatively.

As a result, there are times when a person with brain injury may display inappropriate sexual behaviour and will need support in modifying this behaviour. It is helpful if members of the family are able to become comfortable in discussing sexual issues and to work with their loved one and professionals in implementing behaviour modification techniques.

Impulsivity, disinhibition and lack of awareness may lead to rehabilitation staff receiving unwanted sexual attention from the brain injury survivor. The medical team, family and friends need to have a common response to inappropriate sexual behaviour that will assist the person to regain control over sexual impulses. Behaviours may include fantasising, lewd verbal responses, disrobing and/or masturbating in public, impulsiveness and touching others.

Sexual changes are common after a brain injury. Some of the more common changes include:

• loss of libido or sexual drive
• hyper-sexuality (increased desire for sex)
• inability to achieve or maintain erection
• inability to orgasm
• premature ejaculation
• pain and discomfort during sex
• sexual disinhibition, e.g. talking excessively about sex or inappropriate touching
• reduced sexual responsiveness or desire for intimacy.

These changes may be a direct result of damage which occurred to particular brain structures underlying sexual functioning. Other biological causes of sexual dysfunction may include damage to genital organs, muscles and bones, spinal cord and peripheral nerve damage, medical conditions, hormonal disturbance and side effects of medication and drugs. Psychological and psychosocial changes can also have an impact on sexual function.

Some of the reasons for changes in sexual function include:

• low motivation
• medication
• diabetes or hypertension (high blood pressure) can reduce libido
• depression
• stress and anxiety
• emotional reactions, e.g. anger, embarrassment, shame and fear of rejection
• personality changes
• cognitive problems, e.g. distractibility, perceptual disorders and memory problems
• problems with communication, e.g. aphasia or missing social cues
• a loss of self-confidence regarding personal attractiveness
• poor social skills and impaired self-control
• social avoidance and isolation
• relationship breakdown.

For many people, sex is a personal and private aspect of life, and so seeking professional advice can be an embarrassing and sensitive issue. People are often more likely to discuss sexual problems with their doctor during a visit for other health reasons.

Assessment of sexual problems can be a vital first step in learning to manage or discover treatment options. Assessment may involve an interview, questionnaires, physical examination, and neurological and medical tests.

In addition to a doctor, psychologists and psychiatrists may be involved in the assessment and treatment of sexual problems.

Partner/spouse reactions 

Partners/spouses play a significant role in influencing the injured person’s adjustment to physical and psychosocial changes that affect their sex life. Partners/spouses may consider the following forms of coping:

• developing greater understanding by seeking information on how to support the person with brain injury
• learning different techniques and compensatory strategies, e.g. different ways of giving and receiving pleasure with the person
• altering expectations and negotiating about how often, how long and the type of sexual•activity that is agreed upon by both parties
• being assertive and sensitively communicating personal views
• making changes to lifestyle and routines that improve quality time together.

Children’s social and sexual functioning 

ABI can also affect children’s social and sexual functioning; development may be arrested, or they appear to revert to a previous level of development. In less common situations, a child may develop physical and behavioural changes earlier than their peers. This is often referred to as ‘precocious puberty’.

Families and schools may vary greatly in their approaches to educating children about sexual issues and behavioural management, and it is wise to discuss this with your child’s school. Parents and teachers can access community resources, such as family planning, sexual health clinics and professionals specialising in ABI for support.

Masturbation 

Masturbation is a normal and healthy sexual activity for many people. However, the person with brain injury may need to be reminded that, while it is an appropriate way to deal with sexual urges, it is a private act.

It is important to establish ground rules to protect the rights and privacy of others, so boundaries around masturbation should be discussed e.g. when, where and how.

In some cases, a partner or spouse may continue in a caring role but no longer wish to maintain a sexual relationship, in which case masturbation could be discussed as an option to deal with sexual urges.

Professionals can help individuals cope with a variety of physical and psychosocial changes. Following assessment, specific treatment of sexual challenges may involve education, learning new skills and behavioural techniques, physical rehabilitation, aids and medical treatment. Specific forms of treatment may include psychological support, medical and surgical approaches.

A psychologist or social worker can provide sexual and marital counselling for couples to enhance their understanding of sexual changes, communication skills, problem-solving, conflict resolution and caring behaviours.

Professionals may also provide literature, audiovisual aids and advice on sexual positions, techniques and aids. A psychiatrist may prescribe medication for either psychological or physical problems.

Another important issue is the increased vulnerability that people may experience due to cognitive impairment and emotional distress. In particular, the person may not sense when they are at risk, know how to cope with unwanted sexual advances or understand the consequences of their actions.

Family members and friends need to be aware of these issues and discuss any concerns with a professional. Some people may not feel that it is possible to discuss these issues directly with a person with a brain injury. In such cases, a friend or another family member may be a more appropriate person to recommend self-protection strategies or remind the person about general safety issues.

The medical management of sexual problems is usually most applicable for musculoskeletal, neurochemical and vascular disorders. Some examples include hormonal replacement, new medication such as anti-spasticity drugs or a change of current medication, neurosurgical and orthopaedic procedures.

Jill’s husband, Paul, experienced a number of personality changes after his brain injury. In particular, Paul’s behaviour was immature and he became overly dependent upon Jill.

In many ways, Jill felt like she had become Paul’s mother rather than his wife, friend and lover. The impact on their sexual relationship was significant. Jill read some information about the effects of brain injury. She then organised regular respite care and learned some behaviour management strategies for encouraging Paul to be more independent. As a result of Jill’s increased understanding, some lifestyle changes and new skills, she and Paul now spend more quality time together and their sexual relationship has improved.